May 18, 2022 - Hospitalists weigh which changes they want to carry forward.
IS THE PANDEMIC OVER? At press time, BA.2 rates are on the rise, but hospitalization rates for covid patients are at some of their lowest levels in nearly two years. Now that most hospitals are no longer overwhelmed, many of the rapid pandemic innovations that hospitals and hospitalists rushed to put in place—command centers, parking-lot pods, back-up systems, guideline task forces, daily huddles—are no longer needed and are, for now at least, going dormant.
"We are enjoying another intermission," says Suchita Shah Sata, MD, a hospitalist with Duke University Medical Center in Durham, N.C., speaking in mid-April. "But we're still learning lessons from previous surges that we can apply to the next one, whether it's covid or another disease. We now have all these tools and responses in our back pocket that we can reactivate."
At the same time, hospitalists say they plan to carry forward many pandemic-driven innovations, at least in some form, whether or not another wave breaks.
"Every crisis is an opportunity," says Venkatrao Medarametla, MD, medical director of hospital medicine for Baystate Health in Springfield, Mass. Dr. Medarametla and his colleagues want to retain some of the rapid pace of innovation they experienced during the pandemic. "We've found a new normal, and there is no way we are going back to the old. After two years, our practice has changed."
Virtual meetings are here to stay
As for which innovations Dr. Medarametla and his group plan to keep, virtual meetings is near the top of the list.
Before covid, he explains, staff meetings were always in person. "Out of close to 100 FTEs, we used to see only 15 or 20 people. But with virtual, 50 or 60 people may attend, so we get more engagement and audience."
One more virtual innovation they are holding onto is another communication tool: The e-mail newsletter that Dr. Medarametla used to send every day with covid developments first morphed into a monthly e-mail newsletter. It has since become a daily Zoom call for hospitalists at 7 a.m., lasting only 10 minutes.
"We talk about updates, daily highlights, who did hard work yesterday, the momentum of the day," he notes. "Group members still want to touch base with one another, even briefly."
Hospitalists say that many innovations they want to keep helped streamline care. Within the two St. Peter's Health Partners hospitals in Albany, N.Y., for instance, the pandemic drove a new policy around how clinicians respond to codes. "During a code or rapid response, a whole team of people used to run into the room," says Erica Fish-Merrill, DO, chief of hospitalist medicine. "But with covid, we wanted the fewest potentially exposed."
In what staff now call "protected code blues," only the bedside nurse, respiratory therapist and doctor go in, and they leave the door closed. "The rest of the team waits outside and, during covid, we would sometimes pass
meds through the door or communicate with team members inside via smartphones." While exposure is no longer a concern, says Dr. Fish-Merrill, "we're definitely going to limit the number of people doing codes going forward so our response can be more streamlined."
Better standardized care
Another innovation at St. Peter's resolved problem discharges and created capacity. "Long haulers would stay weeks on eight to 10 liters of oxygen, and we couldn't get them low enough to send home," Dr. Fish-Merrill says. While the hospital kept oxymizers in storage, they received little use because insurance approval caused delays.
But "we had our home supplier give us several, and we started having the respiratory therapists trial them on patients who were stable enough to go home." That bypassed all the insurance hassles—and enabled patients to be discharged on six liters, which the oxymizer potentially boosted to the eight-or-10 liter mark. "That's something we'll definitely carry forward," says Dr. Fish-Merrill, "for COPD patients or those with respiratory failure."
Dr. Sata at Duke says that she and her colleagues—like hospitalists nationwide—realized the benefits of standardizing care pathways for covid patients. In addition to clustering those patients, the hospitalists maintained two dedicated covid rounding lines, with each group member rotating through a week at a time.
"It allowed us to specialize in one disease process," she says. "We realized that even in a hospital medicine group, patients really benefit from that specialization." Her group is now considering what she calls "additional standardization opportunities." One may be their service for patients with threatened limbs; another is the service for patients transitioning from pediatric to adult medicine.
"We had a lot of success taking care of covid patients," says Dr. Sata. "We saw how clustering patients and using dedicated teams reduced variations in care."
Sicker patients, different careers
At The Valley Hospital in Ridgewood, N.J., Jyothi Kulkarni, MD, chair, hospitalist services, says the pandemic accelerated a change that was being discussed even before covid: closing two of her hospital's four critical care units.
Hospitalists used to follow patients into those units and continue their care. But "during the surge, our census really went up." Along with the intensivists, "we decided there was no need to duplicate efforts, plus we wanted to limit people's exposure." Now that the critical care units are being staffed only by intensivists, she points out, "ICU care and throughput have been streamlined."
Baystate hospitalists went the opposite route. During the first covid surge in spring 2020, close to a dozen hospitalists who had some previous ICU experience took crash courses in ventilator management and ACLS. They then worked alongside the intensivists with covid patients in the ICU, as well as treated covid patients on the wards.
While those hospitalists no longer need to attend in the ICU, that experience changed some careers. "Several of them," Dr. Medarametla reports, "have started to pursue critical care fellowships."
Meanwhile, his colleagues are more comfortable taking care of sicker patients than before the pandemic. "We're not calling as many consults," Dr. Medarametla says. "Once you have that comfort level, there's no taking it back."
The same is true for Duke's Dr. Sata and her colleagues: The patients they send to the ICU now are sicker than the ones they'd transfer before the pandemic. Moreover, floor nurses' comfort level with sicker patients is also higher.
"They rose to the challenge of taking care of patients on different types of oxygen delivery—like Optiflow or highflow nasal cannula—than before covid," Dr. Sata points out. "In medicine, we didn't usually question what we might do differently because 'If it ain't broke, don't fix it.' " But with covid, "we had to re-assess the way we do things. It was great to see that inertia broken."
Gregg Miller, MD, chief medical officer for Vituity, a physician-led multispecialty partnership with more than 500 hospitalists nationwide, has noticed this trend: During the pandemic, as more advanced practice providers had to work more productively at the top of their licenses, "physicians became more comfortable with advanced providers' knowledge and skill sets—and with having them move to provide other services."
According to Dr. Miller, the pandemic also drove operational and cultural shifts that will be sustained. One is a closer integration between emergency and hospital medicine.
"We've seen new workflows built out around managing ED boarders or expediting ED discharges, or not admitting lower-acuity patients that the ED used to admit," he says. "ED physicians and hospitalists have now worked out new best practices that will still come into play."
The pandemic also ushered in new levels of inter-facility transfers. "The typical model is for patients to flow from outlying community hospitals to the academic mothership," Dr. Miller says. But during covid, academic centers began transferring less sick inpatients to partner hospitals in the community to free up beds and limit boarding. "That's one innovation I think will stick around."
That's definitely the case at Oregon Health & Science University (OHSU) in Portland, Ore. Stephanie Halvorson, MD, director of OHSU's hospital medicine division, says that the center's ED has for years been admitting patients to its two partner community hospitals.
But "we never did a lot of transfers of existing inpatients," Dr. Halvorson says, "until we had covid surges and needed to free up inpatient beds." That's when the academic center identified long-length-of-stay patients, those who had to remain hospitalized—for IV infusions, for instance, or guardianship decisions—but would be OK with a lower level of acute care.
New care models
Once OHSU started transferring those patients to a unit at an affiliated hospital, "that saved more than 300 inpatient days at the academic center in just the first few months," says Dr. Halvorson. Those transfers contributed to a staffing shortage at the community site, and hospitalists from the main campus temporarily filled some shifts.
"We're now hiring up at the community hospital for long-length-of-stay patients," she notes. "We've decided on a nurse practitioner model."
Vituity's Dr. Miller also underscores the pandemic's tremendous push to the use of telemedicine, with covid surges driving the use of tele-specialties—particularly tele-ID— throughout smaller hospitals. Going forward, hospitalists are exploring the continued use of telemedicine to hold family meetings or provide coverage to rural hospitals.
"That acceleration made significant gains," says Dr. Miller, "but I think we're now leveling off. We're all waiting to see what happens with the public health emergency"— which was extended in April for at least three months—"and payment decisions going forward."Hospitals are also taking a wait-and-see attitude toward another care model that gained major pandemic traction: hospital at home. "People see this as the future," he says, but "everybody now is taking a more guarded approach. Hospital at home is such a complex program with so many moving parts that every program you launch is a brand new start-up."
Going forward, says Dr. Miller, "I think we've broken the mold on the kind of helplessness that used to slow down change, and I hope people are now willing to be more innovative and progressive with the way they deliver care."
At the same time, he says, "we're all struggling with staffing issues, and it's hard to drive change when you don't have the staff to create that change." All that staffing up is expensive, so "you don't have the same resources available to implement capital purchases, like a telemedicine platform."
OHSU's Dr. Halvorson underscores another new reality for hospital medicine: change fatigue. She and her colleagues did get a hospital at home program off the ground in November 2021 that has enrolled "more than 30 patients since. Because the capacity need was so great, that change happened very quickly."
But "the requests for change are still coming fast and furious," she adds. Her COO, for instance, just asked if group members would serve as virtual hospitalists for post-acute patients in SNFs—an idea she believes makes a lot of sense. "But even with hospital at home, which we really like, it's hard to constantly be in a state of change."
That's particularly true when many colleagues, after two brutal years, want to cut back from working full time. "I actually take it as a sign of health that they aren't leaving," Dr. Halvorson says. "But we need more FTEs."
Move to prevent, contain burnout
Burnout is likewise taking a toll at Baystate, Dr. Medarametla says. Some hospitalist colleagues have retired early, while others now want to work only part time, with some cutting back to 0.5 FTE. This is at a time when, he says, "our non-covid census is super-duper high," with clinicians seeing a lot of patients with substance abuse and behavioral disorders.
"We're getting a lot of top-down pressure for discharges to free up beds, and some hospitalist leaders after two years don't want the stress," says Dr. Medarametla. "We're seeing some leave their leadership roles."
At St. Peter's in Albany, preventing burnout informs Dr. Fish-Merrill's approach to leading the hospitalist team. She points out that 2021 was particularly tough; hospitalists were treating successive surges while getting up to speed on a new Epic EHR. In the middle of all that, Dr. Fish-Merrill took over program directorship in April 2021.
"Given what we were going through, I would tell group members, 'This won't be an authoritarian-run program,' " she says. "When people ask what my decision will be going into a meeting, I say, 'Whatever the majority of the group thinks should happen.' I definitely make executive decisions, but we need buy-in and we need everybody to feel like they're part of a team."
And Dr. Kulkarni at The Valley Hospital points out that both hospital and hospitalist leadership moved to provide (and sustain) mental health and wellness resources for staff—resources that aren't going away.
Hospital executives held "resilience rounds," informal wellness checks on the floors to touch base with front-line providers; those have since morphed into "relationship rounds" to check in on staff's wellbeing. For staff, resilience lounges were set up, "virtual drop-in sessions held once a week at three times of the day so everyone who wanted to talk about their experiences could participate," she explains. The hospital has also held virtual Schwartz rounds on resilience for nurses, an eight-hour resilience-building leadership day and a six-week mindfulness program, along with posting a resilience resources handbook on the hospital intranet.
"I think," says Dr. Kulkarni, "resilience building needs to continue in some form forever."
A new level of collaboration
IT'S NOT REALLY AN INNOVATION, but hospitalists point to something else very important that they're taking out of the pandemic: an abiding appreciation for colleagues who worked with them.
At The Valley Hospital in Ridgewood, N.J., Jyothi Kulkarni, MD, chair, hospitalist services, mentions the gratitude she and her group members feel toward their outpatient colleagues who, during what she calls "the mass chaos" of the first surge, rallied and deployed to the hospital. There, they were paired with hospitalist mentors and worked beside them for weeks.
"We were really scared, and having that back-up was a huge morale boost," she says. Group members have always had cordial relationships with outpatient colleagues, Dr. Kulkarni notes. But "that goes to a different level when you work together as a team. That's hard to lose, and it's still going strong."
Suchita Shah Sata, MD, a hospitalist with Duke University Medical Center in Durham, N.C., agrees. "Covid expanded our concept of teams and now it's not just hospital medicine and our nursing colleagues anymore. It's the entire continuum of care, from outpatient providers to the ED and to the ICU and back."
The pandemic has been, Dr. Sata adds, "a terrible experience overall, and I don't want to go through it again. But if I had to, I'd go through it again with these teams."
More innovations to hold onto
WHAT ARE MORE pandemic-driven innovations that hospitalists want to keep? Sources weighed in—and also pointed to previous innovations interrupted by covid that they want to bring back.
"I think that established better working relationships and transfer capabilities across health systems, which until now has always been a challenge," he says. "The pandemic has reinforced the message that we're all in this together."
Stephanie Halvorson, MD, director of the hospital medicine division at Oregon Health & Science University in Portland, Ore., says that even before the pandemic, she began meeting informally with hospitalist leaders from the two other big local programs.
"I guess we are competitors on paper, but they've become wonderful peers," Dr. Halvorson says. That collaboration took on new urgency in the pandemic, and they continue to meet face-to-face once a month. "We come with no agenda, and we always have much more in common than we do differences. I find them really helpful for creative problem-solving and to just pick their brains."
What will continue is what started out during surges as a daily huddle among all the medical directors of all the service lines. That meeting, which was first held every day, is being maintained once a week.
"That's incredibly helpful, and I think it's here to stay," Dr. Halvorson says. "As academics, we used to receive a lot of information through our department chairs. But this meeting delivers much more information directly to the people who are working on the wards."
During the pandemic, OHSU hospitalists changed their back-up policy. "We were fortunate to have a pre-existing backup provider on call," Dr. Halvorson notes, "but we called that person only for illness or acute personal emergencies." That was changed to also include high morning census.
"We're actually calling that person in a lot more, and it's been invaluable," she says. "When we're having a particularly busy day, our teams know that help is on the way."
"We didn't have the luxury of time, and we were short-staffed," Dr. Medarametla points out. "But we're bringing our old onboarding system back. If we don't onboard hospitalists the right way, it takes a long time to undo."
At The Valley Hospital in Ridgewood, N.J., hospitalist director Jyothi Kulkarni, MD, says the pandemic upended unit-based rounding, an innovation put in place years before.
"That had to take a backseat once 90% of the patients in the hospital had covid," Dr. Kulkarni says. "It just became too difficult to manage." She and her colleagues are working re-establish unit-based care. "I would say we're at 40% or 50%, and we're trying to work back to at least 60%," she adds. "The situation is still so fluid that we're taking only slow steps."
"I think that is something that will remain part of decision-making," says Dr. Sata. "I can't imagine hospital leadership from now on not engaging with frontline clinicians going forward."
By Phyllis Maguire
Published in the May/June issue of Today's Hospitalist
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